403 Village Rd - DAVIE COUNTY HEALTW DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
N(j�;E-7"issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name %:=s �tf /4- �� � Date 0 2
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Location `-
%�' �/� •�.1 r ����!:!r/- %. r-� /-� Tom'/. /r� ,f:�=�_<�,.yc•r �
Subdivision Name Lot No. Sec. or Block No.
Lot Sized House Mobile Home ---`` Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO
Auto Dish Washer YES NO E] Specifications for S�.stem:
Auto Wash Machine YES [tj NO Q / �
Type Water Supply %:,1/l�/ __ �;CD�f//
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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2�
Improvements permit by
"Contact a representative of th Davie County Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by °
a
Certificate of Completion Bate
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION r
q9///
Name Date v
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
PS` PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) /'f S� S S S
Clayey Soils / "0 PS PS PS
U U U
4) Soil Depth (inches) S S S
S PS PS PS
U U U U
5) Soil Drainage: Internal S S S
/1-VS PS PS PS
U U U
External S S S S
PS"' PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS PS PS
U
U U U '
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title '2f� Date
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665 -
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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t/ Home Phone 7�3S`
1. Permit Re uested B ce J Business Phone -73
2. Address �k Z3 C //e
3. Property Owner if Different��han Above o b er-6 CIE_
Address ,l}�YIP �--
4. Permit To: a) Install - Alter Y Repair
b) Priv Conventional:Other Type
Ground Absorption
c) Sub-Division Sec. Lot Noyes
5. System used to serve what type facility: House Mobile Home t�� Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms—Bath Rooms�en w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
_ 7. Number and type of wat using fixtures:
commodes e, urinals—!1 garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Com nity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? I
This is to certify that the information is correct to the byeatt off nmy knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
` SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2. Along with the form, remit the amount due as shown on enclosed statement.
3. Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTDIENT,P.O. BOX 57)
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTNMNT
SITE EVALUATION CONSENT FOW1
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
ynot (1.) I am the owner of the above described property.
pi,
yes no (2.) I an not the owner of the above described property, however, I
certify that I have consent from ' ,owner to
awnar s nama
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage
disposal system.
yes no (3.) I hereby •give consent to the authorized representative of the F
Davie County Health Department to Enter upon the above described
property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system.
DATE SIGNATURE `
(4.) I hereby authorize the Davie' County Health Department to release
site evaluation results from the above described property to the
following:
Owner Only
Owner's designated representative
Anyone requesting results
DATEOnly those listed below
SIGNATURE